Laserfiche WebLink
t i <br /> r• V SAN JOAQUIN LOCAL HEALTH. DISTRICT I <br /> F4 OFFICE `USE: . 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit NO. .77--V P <br /> THIS PERMIT EXPIRES l YEAR FROM DATE ISSUED Date Issued . 7 <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct t" , <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION �4 . 1 d d`-� CENSUS TRACT <br /> Owner's Name Phone i <br /> i <br /> Address city <br /> p <br /> Contractor's Name J License #A�Wo <br /> da Phone <br /> i' <br /> TYPE OF WORK (Check) : NEW' WELL L DEEPEN "/ / RECONDITION / DESTRUCTION /-7 <br /> PUMP INSTALLATION PUMP PAIR / / PUMP REPLACEMENT 1�7 i <br /> Other. /�/_ <br /> DISTANCE'TO NEAREST: SEPTIC TANK =- - SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well.. Excavation <br /> Domestic/private Drilled Dia. of Well Casing � <br /> Domestic/public Driven Gauge of Casing \1 <br /> p 8 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information " <br /> Geophysical Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pu H.P. s \; <br /> � <br /> PUMP REPLACEMENT: . / / State Work Done <br /> PUMP .REPAIR: / / State Work Done <br /> DESTRUCTION OF WELL: Well Diamete Approximate Depth <br /> Describe Mate ial andtProcedure <br /> I hereby agree ,to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well'construction. Within FIFTBFN DAYS <br /> after completion of ray work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the -well is use. The above' <br /> information is true to the best of my..knowledge and belief. -I WILL CALL FOR A GROUT INSPECTIM <br /> PRIOR TO GROUTING AND INAL INSPECT N. <br /> SIGNED TITLE <br /> D W:P PLAN 'ON SE SIDE <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED BY \ DATE <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE II I INSPBCTI <br /> INSPECTION BY 11 FET, DATE - INSPECTION BY DATE <br /> V76 <br /> E B 1426 Rev. 1-74 <br /> 2 <br />